The Future of Nuclear Medicine -...
Transcript of The Future of Nuclear Medicine -...
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The Future of Nuclear MedicineTRIUMF: Saturday Morning Lecture Oct 15th 2011TRIUMF: Saturday Morning Lecture, Oct. 15th, 2011
Paul Schaffer | Deputy Head, Nuclear Medicine | TRIUMF
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Overview
• IntroductionIntroduction• Brief History and Molecular Imaging
D fi dDefined• Nuclear Reactors and the ‘Case of the
Missing Isotope’• How (TRIUMF) accelerators will solve the• How (TRIUMF) accelerators will solve the
isotope dilemma • Nuclear Medicine: Today• Nuclear Medicine: Looking Forward
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• Nuclear Medicine: Looking ForwardTRIUMF – Saturday Morning Lecture
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Medical Imaging in Humansg g
neurologycardiology Courtesy of UBC Dept. of Neurologycardiology
Diagnostic and Invasive Cardiology website on November 9, 2006
3oncologyCourtesy of R. Wassenaar, Ottawa Heart Institute
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A Brief Historyy• 1895 – Roentgen discovers X-rays
1896 Edi t d fl• 1896 – Edison created fluoroscope– Becquerel discovered radioactivity (shared Nobel Prize 1903)
• 1898 – M. Curie discovered radium, radioactivity is named1898 M. Curie discovered radium, radioactivity is named– (shared Nobel Prize 1903)
• 1911 – George de Hevesy – first use of tracer, est. ‘Tracer Principle’ (Nobel Prize 1943 – recast in 1946 (?))
4all images from wikipedia.org
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A Brief Historyy
• 1958 – Hal Anger – gamma camera• 1973 – Phelps invents PET scanner• 1980 – PET program starts at TRIUMF• 1998 – [18F]FDG gains regulatory approval for reimbursement
in USA• 2000 PET/CT is Time’s invention of the year• 2000 – PET/CT is Time s invention of the year• 2003 – Health Canada introduces FDG into clinical trials
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PET in Canada todayy
C d h i l t i f t t• Canada has a growing cyclotron infrastructure• Disease focus: Oncology, Neurology and Cardiology
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Molecular Imaging Definedg g
… the in vivo characterization and measurement of biological processes at the cellular and molecular level…to probe the molecular abnormalities that are the basis of disease rather than to image the end effects…1
1 R Weissleder and U Mahmood Radiology 2001 219 p316
…directly or indirectly monitor and record the spatiotemporal
1 R Weissleder and U Mahmood, Radiology 2001, 219, p316
…directly or indirectly monitor and record the spatiotemporal distribution of molecular or cellular processes for biochemical, biologic, diagnostic, or therapeutic applications.2,3
3 WC Eckelman, Nuclear Medicine and Biology 2006, 33, p1
2 M Thakur and BC Lentle, Radiology 2005, 236, p753
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SPECT vs. PET Imagingg g
PET SPECTInexpensive, widely avail.Significant infrastructure
Higher sensitivity, resolution
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g
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Positron Emission for PET
9Angew. Chem. Int. Ed. 2008, 47, 8998 – 9033
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Gamma (Single Photon) Emission for SPECTSPECT
GammaGamma(Anger)camera
Rotational path around patient
10October 15, 2011 TRIUMF – Saturday Morning Lecturewww.nytimes.com
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Functional Imaging is great, but…g g g
Wh t l ki t ?11TRIUMF – Saturday Morning Lecture
What are we looking at, anyway?
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Multimodal Imagingg g
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Where the freq. is PET?
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A Hynes et al. BMC Molecular Imaging 2005, 5, 2
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Comparing Imaging Methodsg g g
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The Nuclear Medicine Process
TargetDev.
IsotopeProd.
Tracer Prod.
(Pre)clinicalStudies
DetectorDev.
CyclotronDev.
www.wattcon.comCourtesy of the PPRC
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www.bccancerfoundation.com Courtesy of the PPRC
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TRIUMF’s Nuclear Medicine Expertise?Medicine Expertise?
TargetDev
IsotopeProd
Tracer Prod
(Pre)clinicalStudies
DetectorDev
CyclotronDev Dev. Prod. Prod. Studies Dev.Dev.
Historical and Core Capabilities
Driven by ourPartners:Capabilities Partners:
UBC/PPRCBCCABCCA
NordionGE
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Isotope Production - Acceleration
• Accelerator/Cyclotron ProductionAccelerator/Cyclotron Production
• Located near or in hospitals• Produce short lived isotopes on demand
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• Produce short-lived isotopes on demand
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Medical cyclotrons
• Medical cyclotrons are already running in Canada’s major
y
cities to produce PET isotopes
nFOH 10
189
188
11 +⎯→⎯+ 18O(p,n)18Fn F O H 0981 +→+
HeN O 42
137
11 +⎯→⎯+ 16
8 H
(p, )
16O(p,α)13N271 8
eHCN 42
116
11 +⎯→⎯+ 14
7H
(p, )
14N(p,α)11C
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eHC N 261 +→+ 7 H (p )
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A brief history of 99mTcy• BNL, 1950s: Walter Tucker and
Margaret Green discovered Tc-99mMargaret Green discovered Tc 99m as a ‘contaminant’ and developed the first 99Mo/99mTc generator (1957)
• BNL, 1960: Powell Richards, newly in charge of isotope production, presented the first paper at the 7thpresented the first paper at the 7International Electronic and Nuclear Symposium.
• Richards met with Paul Harper on the flight to Rome and spent the flight “extolling the merits of 99mTc”flight extolling the merits of 99mTc
• By 1966 BNL backed out of generator production in favour of
19
g pcommercial suppliers
From http://www.bnl.gov/bnlweb/history/Tc-99m.asp
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From U-235 to Tc-99m
TargetIrrad.
IsotopeIsolation
Tracer Prod.
HumanUse
Accelerator/Reactor
Imaging Technology News, June 2009
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Making Mo-99 from U-235g
99
N 235U 236U
99Mo
gammaN
N 235U U
Other
N
isotopes
Natural Uranium: ~ 0.8% U-235, 99.2% U-238Low Enriched Uranium (LEU): <20% U-235Low Enriched Uranium (LEU): <20% U 235
Highly Enriched Uranium (HEU): >85% U-235
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SPECT: Isotope Generators
Moly ‘Cow’y
•TransportableTransportable•Easy to use•‘Recyclable’
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• Tc-99m generator is SPECT enabler TRIUMF – Saturday Morning Lecture
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Tc-99 Generators
•Transportable•Easy to use•‘Recyclable’
• Tc-99m is “milked”Tc 99m is milked from the generator
• Tc-99m is tagged to c 99 s tagged totracers and then injected into the patient
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Canada’s Role in the Recent(Global) Isotope Crisis(Global) Isotope Crisis
• Global demand for 99Mo/99mTc ~ 40 million doses/yrGlobal demand for Mo/ Tc 40 million doses/yr• 76,000 scans/day (>1 scan/second)• 30-40% of global 99Mo obtained from NRU in Canadag• Overall, 5 gov’t owned reactors supply >95% of global demand• Future demands to increase
• Recent NRU shutdown: widespread shortages, cost/mCiescalating
• Adding suppliers faces technical and regulatory challenges
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The MAPLESMAPLE: Multipurpose Applied Physics Lattice Experiment
• Two identical reactors• Purpose: to succeed NRX (1992) and NRU (2016?)Purpose: to succeed NRX (1992) and NRU (2016?)• Construction started 1997, completed 2000• Dedicated isotope production (99Mo, 60Co, 133Xe, 131I, 125I)• Capable of producing 200% of global 99Mo/99mTc demand
Issues (there are many)*:Issues (there are many) :• sticky shut-off safety system• positive co-efficient of reactivityp y• use of HEU• operating license until 10/31/2011
j t t i t d 5/16/200815 October 2011 25
• project terminated 5/16/2008
* Issues are the sole opinion of the presenter
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Alternatives for Tc-99m production• 1950’s and 60’s 235U(n,F)99Mo/99mTc generators gain
widespread use Continues today From http://www bnl gov/bnlweb/history/Tc-99m aspwidespread use. Continues today. • 2007 – Several prolonged shutdowns of major production
reactors highlight 99Mo supply vulnerability
From http://www.bnl.gov/bnlweb/history/Tc 99m.asp
• Alternatives are well known• at various stages of commercial-scale production:at various stages of commercial scale production:
Neutron ‘solution(s)’: LEU 235U(n,F)99Mo
98Mo(n,γ)99MoPhoton ‘solution(s)’:
238U( F)99Mo238U(γ,F)99Mo100Mo(γ,n)99Mo
Proton ‘solution’:Proton solution :100Mo(p,2n)99mTc
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100Mo(p,2n)99mTc( )
• 1971 – Beaver and Hupf* report 100Mo(p,2n)99mTc
• 1999-2010 several reports on cross-sectional measurement• 2011 – Gagnon et al.** re-measure 99mTc and determine 99gTc
ti R fi d d ti i ld t 9 6 Ci i 1h ithcross sections. Refined production yield to 9.6 Ci in 1hr with 99m/99g ratios of 25% (@22 MeV)
*J B H H f J N l M d 1971 12 739 741*J. Beaver, H. Hupf, J Nucl Med 1971;12:739-741** K Gagnon et al. Nuc. Med. Biol. 2011, in press
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Isotope Crisis Alternative: Cyclotrons
Alternatives:98Mo(n γ)99Mo98Mo(n,γ)99Mo
LEU
238U(γ,F)99Mo100Mo(γ,n)99Mo
28graphic from http://www.covidien.com/
100Mo(p,2n)99mTc
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Direct Production of 99mTc
To demonstrate existing100Mo Target
C l t100M
To demonstrate existingcyclotron network….
Cyclotron Modifications
100Mo Recycle
100Mo(p 2n)99mTcIrradiation
ParametersRegulatory
100Mo(p,2n)99mTc
Purificationf 99 T O
…can produce commercial quantities
of 99mTcO4-
Goal: To change the global thinking on 99mTc production
qof 99mTc
Goal: To change the global thinking on Tc production• Help formulate Government of Canada policy
on 99Mo/99mTc medical isotope production
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Theoretical Yields
100Mo(p,2n)99mTc
3 critical criteria:1) Energy of protons
100Mo(p,pn)99Mo2) Proton current
3) Time
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Projected Production Capabilitiesj
Theoretical Activity at EOB (Ci)
CyclotronEnergy (MeV)
Current (mA)
Irradiation Time (hours)
19 0.2 3 6.119 0.2 6 10.419 0 2 12 15 6
at EOB (Ci)(MeV) (mA) (hours)
YVR19 0.2 12 15.624 0.2 3 8.624 0.2 6 14.724 0.2 12 22.1
CP42
19 0.2 3 6.119 0.2 6 10.419 0.2 12 15.619 0 5 3 21 4
TR1919 0.5 3 21.419 0.5 6 36.719 0.5 12 55.117.5 0.08 3 217.5 0.08 6 3.417.5 0.08 12 5.117.5 0.16 3 417 5 0 16 6 6 8
GE PETtrace
31
17.5 0.16 6 6.817.5 0.16 12 10.2
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Target Housing
TRIUMF-design and manufacture
Low current: 50 µA Intermediate current: <100 µA High Current >150 µA
Questions to answer:• Which proton energy are we using?• What current are we using?• How long are we irradiating?g gAlso:• How do we move material when done?• Turnaround for next run
Goal: > 100 μA, 16.5 to 18 MeV, 3 - 6 hours
Turnaround for next run
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Target Housing Installation at BCCAg g
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Target Plate Manufactureg
Target Design and Function-High risk!• Fewer than 10 reports on aqueous deposition of Moaqueous deposition of Mo
• Aqueous preferred (MoO42-)
• All report <1 μm coatings
• Require Teff > 300 µm
Three parallel efforts: electroplating, sintering and sputtering
Energy (MeV) Thickness 100Mo (μm)
Mass 100Mo (mg)
GE (16.5-10) 317 564-1003actual
effTT =
34
ACSI (18.5-10) 408 320-818CP42 (22-10) 673 1239
θsinff
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Electroplating Resultsg
Early efforts - three outcomes;1) No deposit
Possible variables:
1) No deposit2) Black deposit MoOx3) Metallic deposit (<1μm)
Current, pH, Temperature, [MoO42-], counterion,
Agitation, Additives, Cell (anode, cathode) composition, Duration
Hints from literature:Organic acid to stabilize intermediate Mo statesSequester the available waterSequester the available waterUse a saturated electrolyte with ligand salt
Result: Metal (not oxide) deposit, up to ~30μmRecall – need Teff >300μm
O ti i ti tiOptimization continues:Contingency plans to utilize sintered Mo
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Quality Tools for Focused ResearchScreening Experiments: pH, current, agitation, electrolyte volume, [MoO4
2-]Identified current and pH as most important
Mass ( )
Adherence
8
10
12
2.5
3 (mg)
4
6
8
Mas
s
1.5
2
Qua
lity
0.5 6.2
0
2
0.5 6.2
1
1.5
0.2
0.3
0.4
7.0
6.8
6.6
6.4
A: pH B: Current Density 0.2
0.3
0.4
7.0
6.8
6.6
6.4
A: pH B: Current Density Current CurrentpH pH
7.0
Abandoned for similar, but more effective approach 36
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99mTcO4 Purification4
Irradiations performed up to 30 µA 15-18 MeV for 1 hour
Activity (mCi)
Irradiations performed up to 30 µA, 15 18 MeV for 1 hourGoal: > 100 µA, 16.5 to 18 MeV, 3 hours
Isotope 1μm target 5μm target >400μm target*Tc-99m 0.4 3.0 95Mo 99 0 003 0 03 unknownMo-99 0.003 0.03 unknown
Tc-95/96/97 detected at the <10 kBq level *produced using alternative method
37
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Automated Isotope Purification
Remote separation system• Dissolution: rapid in H2O2• Ion exchange: Dowex™ vs ABEC
• Dowex is flow dependentDowex is flow dependent • Capture @ <2mL/min, release @ <1 mL/min
• Time: complete in <30 min.• Efficiency:• Efficiency:
•Dowex: 72% (35 min)•ABEC >90% (30 min)
Radiochemical Purity: >99 99% TcO• Radiochemical Purity: >99.99% TcO4• Trace analysis: <10 Bq Mo-99, <5 ppm Al3+
O h T i d d 97T 96T 95T• Other Tc isotopes detected: 97Tc, 96Tc, 95Tc• 97.39% enriched 100Mo used
•May require higher enrichement (99.1%)
38
McAlister and Horwitz, Appl.Radiat. Isotope 2009, 67, 1985 (two-column approach)Chattopadhyay et al. Appl. RadiatI. Sotop. 2008, 66, 1814 (Dowex)
Bond et al. Ind. Eng. Chem. Res. 1999,38, 1683 (ABEC)
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Direct Production of 99mTc
To demonstrate existing100Mo Target
C l t100M
To demonstrate existingcyclotron network….
Cyclotron Modifications
100Mo Recycle
100Mo(p 2n)99mTcIrradiation
ParametersRegulatory
100Mo(p,2n)99mTc
Purificationf 99 T O
…can produce commercial quantities
of 99mTcO4-
Goal: To change the global thinking on 99mTc production
qof 99mTc
Goal: To change the global thinking on Tc production• Help formulate Government of Canada policy
on 99Mo/99mTc medical isotope production
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Nuclear Medicine: Moving Forwardg
Hypothesis: Nuclear pharmacies will shift to rely entirely onHypothesis: Nuclear pharmacies will shift to rely entirely on accelerators for production of medical isotopes within 10
years• If accelerators can produce isotopes traditionally obtained
from nuclear reactors at similar cost, quality, then d ti b t b b l tproduction by reactor becomes obsolete
• Many other isotopes are produced using hospital-based accelerators (cyclotrons)accelerators (cyclotrons)
• Positron emitters comprise of growing list of isotopes used for imagingg g
• Many hospitals are developing in-house expertise to produce and study novel radiopharmaceuticals
40TRIUMF – Saturday Morning Lecture
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Imaging Mechanismsg g
Three mechanisms for (targeted) tracer uptakeThree mechanisms for (targeted) tracer uptakeNon-targeted1) PerfusionTargetedTargeted1) Binding – cell surface markers2) Accumulation – transport / metabolism3) Conversion – activates probe (not for PET)3) Conversion – activates probe (not for PET)
41TRIUMF – Saturday Morning Lecture
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Perfusion Imagingg g
42TRIUMF – Saturday Morning Lecture
www.medicexchange.com
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Targeted Imaging:Mechanism of Action BindingMechanism of Action - Binding
tracertracer
Cell/tissueof interest
Cell/tissueof interest
time
receptor
43TRIUMF – Saturday Morning Lecture
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Targeted Imaging:Mechanism of Action Accumulation
tracer
Mechanism of Action - Accumulation
Cell/tissue Cell/tissuetimeCell/tissue
of interestCell/tissueof interest
PO32-PO32-transporter
Hexokinase
PhosphoglucoseIsomerase
PO3
Hexokinase
PhosphoglucoseIsomerase
PO3
ATP ADPATP ADP 44
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What Types of MI agents use PET?y g
45TRIUMF – Saturday Morning Lecture
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Labeling Approachesg
• IntegratedIntegrated• Direct, non-regiospecific• Direct, regiospecific, • Indirect regiospecificIndirect, regiospecific• Indirect non-regiospecific
46Chemical Society Reviews, 1998, 27, 43
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The Paradigms of Nuclear Medicineg
PETSPECT
Na[99mTcO4]
Chelakit
vect
or
vect
or
99mTc
Chelakit‘Shake and Shoot’
halflife keVTc-99m 6 hrs 140
I-123 13 hrs 159
halflife MeVF-18 110 min 0.64C-11 ~20 min 0.96N 13 10 i 1 2I-123 13 hrs 159
In-111 2.8 d 171 / 245Ga-67 3.3 d 93/184/300
N-13 ~10 min 1.2O-15 ~2min 1.73
Ga-68 68 min 1.9Cu 64 ~13 hrs 0 65
47
Cu-64 ~13 hrs 0.65
TRIUMF – Saturday Morning Lecture
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pH temp. conc.pH p conc.
>10kDaμLg
8kDa
14 <65oC
8kDa
mass volume
mol. wt.mLmg>90oC0
mol. wt.construct
dependent
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Attributes of Large Mol. Wt. Vectorsg
– peptides easily diffuse into tissue (better than t i )proteins)
– tunable specificity– good clearance profiles from non-target
tissue (good signal-to-noise)(g g )– low toxicity/immunogenicity
NH2 NHNH2 NHNH2 NHNH
NH2 NH
NHNHNHNH2
N
ONH
NH
N
ONH
N
ONH
N
ONH
N
ONH
N
OOHN
H
NN
NH
NHNH
NH
NHNH
NH
O
NH
NH2
O
NH
O
NH
O NH2
O
NH
O
NH
OO
+
49
M
COCOOC
NNNH2NHNH2NH
M = 99mTc, ReTRIUMF – Saturday Morning Lecture
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Tc-99m Chemistry: Exampley
OOOO
NH
ONN
N
O
SNH
HNNH
N
O
S99mTcO4
Tc
O
NN
N N
OOH
HNNH
N N
OHOH
Che
laki
t
50TRIUMF – Saturday Morning Lecture
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F-18 Chemistry for Large Mol. Wt.
H
O
H
O
+N+
N+
H
O 18F[18F]KFK222K2CO3
18FN
OO
NH2N
O
S
H
ON
O
O
S
HN
O
ON
NH
NH2
O
18Fcitric acid buffer (pH 3.0)30 min, 20%60°C
N
O
O
S
HN
O
ON
18F1) purify2) formulate
51
O
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Medical Imaging in Humans - futureg g
Alzheimer’s Breast Cancer
ON
O
11CH3H
H
11CH3H
H Tc
N
NO
N
N
NO
N
52
N
O
O
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…and other conditions
Presentation Title 53
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Observing the Placebo Effect…g
“…the act of receiving any treatment may, in itself, be efficacious because of expectation of benefit ”
PPRC
because of expectation of benefit.Parkinson’s patient brain
scan showingscan showing 11C-raclopride accumulation
11
O NH CH2
NH
Cl Cl
HO O11CH3CH2CH3
When told they had a possibility of being
i d f b fitgiven drug of benefit
First demonstration of neurochemical effect of placebo54
R. de la Fuente-Fernandez et al. Science 2001, 293, 1164.
First demonstration of neurochemical effect of placebo
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11C containing tracers 18F containing tracers
Core Program at TRIUMF
H OOH OO NN
Raclopride• Parkinsons• D2 antagonist
DTBZ• Parkinsons/Diabetes• target: VMAT2
11C containing tracers 18F containing tracersF-DOPA• Parkinsons• Dopamine metabolism
EF5• Hypoxia
PPRC
18F18F
H311C
H
H311C
H
H
11CH3
H
Cl
O
O
N
N
O
ClH
11CH3
H
Cl
O
O
N
N
O
Cl NO2
18FN
N
F
FFF
O
NO2
18FN
N
F
FFF
O
Methylphenidate Methionine
p
Setoperone
18F18F
18F18F
H11CH3
H11CH3
y p• Parkinsons• DAT binder
• Oncology (brain, lung, breast)• target: AA transport FDG
• Oncology/Neurology • Glucose Transport
Setoperone
SPARQOHH311CH311C
CF3
18FCF3
18F
HN O
O
HN O
O
Sch233900• Parkinsons
D1 t i t
PK11195• Brain injury/inflammation• PBR receptor FHBG
SPARQ• Neurology• Neurokinin
O
OH
HOHO
18F
18F
NH
NNH2N
NOH
O
18F
NH
NNH2N
NOH
O11CH311CH3
HPh
H
HPh
H11CH311CH3
• D1 antagonist
PMP
11CH3H 11CH3HOONC CNNC CN
HH
PIB• Alzheimer’s• target: β amyloid
PMP• Alzheimer’s, Parkinsons, epilepsy• AChE activity
FDDNP• Alzheimer’s• target: β amyloid
FLT• Oncology• Thymidine Kinase
CH3H
H
CH3H
H18FOH
OH
NH2
18FOH
OH
NH218F18F
H311CH311C
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PPRC: Probing the Dopamine System
CH2NH2
HO 18F-FDopa
PPRC
CH2 C 2
CO2HHHO
18F
HO HHN
H
N
HO H
H11CH3O
C6H5H311CO2C
H
d-threo-MethylphenidateCH3O
N11CH3
Cl
HOH
DATDihydrotetrabenazine
HO O11CH3
O NH CH2
NH
CH2CH3
H
Sch233900
Cl Cl
2 3
Raclopride
56
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Infrastructure Upgrades: GMP Facilitiesg• WD Canada: $911,000 (retrofit GMP upgrade)
Thanks to: Nuc Med Team Tim Meyer Shirley Reeve– Thanks to: Nuc. Med. Team, Tim Meyer, Shirley Reeve
Not present: Linda Graham, James Inkster
57
James Inkster, Tom Morley
Photos by: Mindy Hapke
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AcknowledgementsgTRIUMF TeamKen Buckley
LeadershipNigel LockyerKen Buckley
Maurice Dodd
Wade English
Nigel LockyerJean-Michel PoutissouTom RuthWade English
Kathleen Genge
Linda Graham
Mike AdamTim MeyerShirley Reeve
Vicky Hanemaayer
Conny HoehrCollaboratorsBCCA (F. Bénard)
Shirley Reeve
James Inkster
Salma Jivan
J li Kl
UBC Engineering (E Asselin), MIRG (A Celler)Edmonton (S McQuarrie, D Abrams, K Gagnon, J Wilson)Lawson (F Prato, M Kovacs)
Julius Klug
Tom Morley
Christine Takhar
( , )Sherbrooke (B Guerin)CPDC (J Valliant), AAPS (C Campbell)Advanced Cyclotron Systems Inc
58
Christine Takhar
Stefan ZeislerAdvanced Cyclotron Systems, Inc.GE Healthcare
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Thank You!Merci!Merci!
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